What can be done?

A word that has been used with regard to antibiotic use is stewardship - this refers to the prudent and judicious use of these drugs in an effort to curb the infective efforts of the swelling bacterial underground. Encompassed in such an approach are such concepts as restricting the in-hospital use of broad-spectrum antibiotics, such as third-generation cephalosporins. (9)

Other infection control measures that include such simple hygiene practices as diligent hand-washing can help engineer microbial barriers that can limit horizontal nosocomial infections.

These and other infection control measures provide a measure of comfort, but the question of actual treatment is next on the agenda. A study conducted in India at one tertiary care center from 1995 to 1996 showed that bacterial drug resistance to common antibiotics such as ampicillin, chloramphenicol, cotrimoxazole, and first-generation cephalosporins ranged from 73 to 99 percent among gram-negative isolates. Resistance to amikacin and third-generation cephalosporins was as high as 73 percent. As many as 11.5 percent of all isolates proved to be resistant to all available antibiotics. The researchers also noted an increase in methicillin-resistant staphylococci from 52 to 65 percent. (12)

In the United States, S. aureus is one of the most common causes of nosocomial and community-acquired infection. Today, as many as 80 percent of S. aureus isolates are resistant to penicillin. In the 1980's, MRSA became common in many hospitals.

Recent studies have shown that MRSA is now found beyond the hospital and special-risk groups. There also have been reports of increasing incidence of outpatient MRSA infections in adults and children. (13) In 1997, two infections due to S. aureus with reduced susceptibility to vancomycin were identified. (11)

A major problem that has appeared in many U.S. health-care settings is the presence of vancomycin-resistant enterococci (VRE). Most of these organisms are resistant to all current antimicrobial agents. Additionally, they have a high potential to transfer their resistance to other species. Because of these problems, Moellering wrote in his 1998 article in Clinical Infectious Diseases that the recommendations made by members of an expert panel in 1987 still hold true for the year 1998; the panel concluded that "for the remainder of this century, it appears that the development of new chemical entities, designed to overcome or circumvent resistance, constitutes the best prospect for dealing with resistance." (14)